Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU

Critical Care

E Søreide²  T Draegni⁶  JK Heltne¹  JT Kvaløy³  AI Larsen²  K Sunde⁷  J Langørgen⁴  TW Lindner⁵ 

[1] Department of Anaesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway;Department of Clinical Medicine, University of Bergen, Norway;Department of Mathematics and Natural Sciences, University of Stavanger, Norway;Department of Heart Disease, Haukeland University Hospital, Bergen, Norway;Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Norway;Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway;Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Norway

关键词: intensive care;    gender;    age;    survival;    therapeutic hypothermia;    Out-of-hospital cardiac arrest;   

Others  :  818007
DOI  :  10.1186/cc12826

 received in 2013-03-02, accepted in 2013-07-23,  发布年份 2013

【 摘 要 】

Introduction

Therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) was adopted early in Norway. Since 2004 the general recommendation has been to cool all unconscious OHCA patients treated in the intensive care unit (ICU), but the decision to cool individual patients was left to the responsible physician. We assessed factors that were associated with use of TH and predicted survival.

Method

We conducted a retrospective observational study of prospectively collected cardiac arrest and ICU registry data from 2004 to 2008 at three university hospitals.

Results

A total of 715 unconscious patients older than 18 years of age, who suffered OHCA of both cardiac and non-cardiac causes, were included. With an overall TH use of 70%, the survival to discharge was 42%, with 90% of the survivors having a favourable cerebral outcome. Known positive prognostic factors such as witnessed arrest, bystander cardio pulmonary resuscitation (CPR), shockable rhythm and cardiac origin were all positive predictors of TH use and survival. On the other side, increasing age predicted a lower utilisation of TH: Odds Ratio (OR), 0.96 (95% CI, 0.94 to 0.97); as well as a lower survival: OR 0.96 (95% CI, 0.94 to 0.97). Female gender was also associated with a lower use of TH: OR 0.65 (95% CI, 0.43 to 0.97); and a poorer survival: OR 0.57 (95% CI, 0.36 to 0.92). After correcting for other prognostic factors, use of TH remained an independent predictor of improved survival with OR 1.91 (95% CI 1.18-3.06; P <0.001). Analysing subgroups divided after initial rhythm, these effects remained unchanged for patients with shockable rhythm, but not for patients with non-shockable rhythm where use of TH and female gender lost their predictive value.

Conclusions

Although TH was used in the majority of unconscious OHCA patients admitted to the ICU, actual use varied significantly between subgroups. Increasing age predicted both a decreased utilisation of TH as well as lower survival. Further, in patients with a shockable rhythm female gender predicted both a lower use of TH and poorer survival. Our results indicate an underutilisation of TH in some subgroups. Hence, more research on factors affecting TH use and the associated outcomes in subgroups of post-resuscitation patients is needed.

【 授权许可】

   
2013 Lindner et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002, 346:557-563.
• [2]Hypothermia after Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002, 346:549-556.
• [3]Nolan JP, Morley PT, Vanden Hoek TL, Hickey RW, Kloeck WG, Billi J, Böttiger BW, Morley PT, Nolan JP, Okada K, Reyes C, Shuster M, Steen PA, Weil MH, Wenzel V, Hickey RW, Carli P, Vanden Hoek TL, Atkins D, International Liaison Committee on Resuscitation: Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation 2003, 108:118-121.
• [4]Busch M, Soreide E: Prognostication after out-of-hospital cardiac arrest, a clinical survey. Scand J Trauma Resusc Emerg Med 2008, 16:9. BioMed Central Full Text
• [5]Busch M, Soreide E, Lossius HM, Lexow K, Dickstein K: Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors. Acta Anaesthesiol Scand 2006, 50:1277-1283.
• [6]Soreide E, Sunde K: Therapeutic hypothermia after out-of hospital cardiac arrest: how to secure worldwide implementation. Curr Opin Anaesthesiol 2008, 21:209-215.
• [7]Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, Draegni T, Steen PA: Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 2007, 73:29-39.
• [8]Sunde K, Soreide E, Jacobsen D, Steen PA: [Therapeutic hypothermia after cardiac arrest saves more lives!]. Tidsskr Nor Laegeforen 2004, 124:925-926.
• [9]Hovdenes J, Laake JH, Aaberge L, Haugaa H, Bugge JF: Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock. Acta Anaesthesiol Scand 2007, 51:137-142.
• [10]Sterz F, Holzer M, Roine R, Zeiner A, Losert H, Eisenburger P, Uray T, Behringer W: Hypothermia after cardiac arrest: a treatment that works. Curr Opin Crit Care 2003, 9:205-210.
• [11]Larsen AI, Melberg TH, Bonarjee V, Barvik S, Nilsen DW: Change to a primary PCI program increases number of patients offered reperfusion therapy and significantly reduces mortality: a real life experience evaluating the initiation of a primary PCI service at a single center without on site heart surgery in Western Norway. Int J Cardiol 2008, 127:208-213.
• [12]Våga A, Busch M, Karlsen TE, Nilsen OB, Soreide E: A pilot study of key nursing aspects with different cooling methods and devices in the ICU. Resuscitation 2008, 76:25-30.
• [13]Langhelle A, Lossius HM, Silfvast T, Bjornsson HM, Lippert FK, Ersson A, Soreide E: International EMS Systems: the Nordic countries. Resuscitation 2004, 61:9-21.
• [14]Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G: European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005, (Suppl 1):S39-86.
• [15]Part 1: introduction to the International Guidelines 2000 for CPR and ECC. A consensus on science. European Resuscitation Council Resuscitation 2000, 46:3-15.
• [16]Lexow K, Sunde K: Why Norwegian 2005 guidelines differs slightly from the ERC guidelines. Resuscitation 2007, 72:490-492.
• [17]Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coovadia A, D'Este K, Finn J, Halperin H, Handley A, Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL, Mancini ME, Mason P, Mears G, Monsieurs K, Montgomery W, Morley P, Nichol G, Nolan J, Okada K, Perlman J, Shuster M, Steen PA, Sterz F, et al.: Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa). Resuscitation 2004, 63:233-249.
• [18]The Northern Hypothermia Registry [http://www.scctg.org/NHN/NHNWelcome.htm] webcite Accessed on December10th 2011
• [19]Holzer M: Devices for rapid induction of hypothermia. Eur J Anaesthesiol Suppl 2008, 42:31-38.
• [20]D'Agostino RB: Propensity scores in cardiovascular research. Circulation 2007, 115:2340-2343.
• [21]Williamson E, Morley R, Lucas A, Carpenter J: Propensity scores: from naive enthusiasm to intuitive understanding. Stat Methods Med Res 2012, 21:273-293.
• [22]Martinell L, Larsson M, Bang A, Karlsson T, Lindqvist J, Thoren AB, Herlitz J: Survival in out-of-hospital cardiac arrest before and after use of advanced postresuscitation care: a survey focusing on incidence, patient characteristics, survival, and estimated cerebral function after postresuscitation care. Am J Emerg Med 2010, 28:543-551.
• [23]Sandroni C, Cavallaro F, Antonelli M: Therapeutic hypothermia: is it effective for non-VF/VT cardiac arrest? Crit Care 2013, 17:215. BioMed Central Full Text
• [24]Vaahersalo J, Hiltunen P, Tiainen M, Oksanen T, Kaukonen KM, Kurola J, Ruokonen E, Tenhunen J, Ala-Kokko T, Lund V, Reinikainen M, Kiviniemi O, Silfvast T, Kuisma M, Varpula T, Pettilä V, FINNRESUSCI Study Group: Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study. Intensive Care Med 2013, 39:826-837.
• [25]Xiao G, Guo Q, Shu M, Xie X, Deng J, Zhu Y, Wan C: Safety profile and outcome of mild therapeutic hypothermia in patients following cardiac arrest: systematic review and meta-analysis. Emerg Med J 2013, 30:91-100.
• [26]Dumas F, Grimaldi D, Zuber B, Fichet J, Charpentier J, Pène F, Vivien B, Varenne O, Carli P, Jouven X, Empana JP, Cariou A: Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients? Insights from a large registry. Circulation 2011, 123:877-886.
• [27]Rittenberger JC, Callaway CW: Muddy waters: Hypothermia does not work? Resuscitation 2011, 82:1120-1.
• [28]Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW: Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms? A systematic review and meta-analysis of randomized and non-randomized studies. Resuscitation 2012, 83:188-196.
• [29]Lundbye JB, Rai M, Ramu B, Hosseini-Khalili A, Li D, Slim HB, Bhavnani SP, Nair SU, Kluger J: Therapeutic hypothermia is associated with improved neurologic outcome and survival in cardiac arrest survivors of non-shockable rhythms. Resuscitation 2012, 83:202-207.
• [30]2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4: Advanced life support Resuscitation 2005, 67:213-247.
• [31]Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, Hatanaka T, Hazinski MF, Jacobs I, Monsieurs K, Morley PT, Nolan JP, Travers AH: Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010, (Suppl 1):e48-70.
• [32]Busch M, Søreide E: Should advanced age be a limiting factor in providing therapeutic hypothermia to cardiac arrest survivors? A single-center observational study. Ther Hypothermia Temp Manag 2011, 1:29-32.
• [33]Garrouste-Orgeas M, Boumendil A, Pateron D, Aergerter P, Somme D, Simon T, Guidet B, Group I-C: Selection of intensive care unit admission criteria for patients aged 80 years and over and compliance of emergency and intensive care unit physicians with the selected criteria: An observational, multicenter, prospective study. Crit Care Med 2009, 37:2919-2928.
• [34]Sprung CL, Artigas A, Kesecioglu J, Pezzi A, Wiis J, Pirracchio R, Baras M, Edbrooke DL, Pesenti A, Bakker J, Hargreaves C, Gurman G, Cohen SL, Lippert A, Payen D, Corbella D, Iapichino G: The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly. Crit Care Med 2012, 40:132-138.
• [35]Haglund B, Koster M, Nilsson T, Rosen M: Inequality in access to coronary revascularization in Sweden. Scand Cardiovasc J 2004, 38:334-339.
• [36]Thompson CA, Kaplan AV, Friedman BJ, Jayne JE, Gerling BR, Niles NW, Hettleman BD, Robb JF: Gender-based differences of percutaneous coronary intervention in the drug-eluting stent era. Catheter Cardiovasc Interv 2006, 67:25-31.
• [37]Eapen ZJ, Peterson ED, Fonarow GC, Sanders GD, Yancy CW, Sears SF Jr, Carlson MD, Curtis AB, Hall LL, Hayes DL, Hernandez AF, Mirro M, Prystowsky E, Russo AM, Thomas KL, Al-Khatib SM: Quality of care for sudden cardiac arrest: Proposed steps to improve the translation of evidence into practice. Am Heart J 2011, 162:222-231.
• [38]Poon S, Goodman SG, Yan RT, Bugiardini R, Bierman AS, Eagle KA, Johnston N, Huynh T, Grondin FR, Schenck-Gustafsson K, Yan AT: Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes. Am Heart J 2012, 163:66-73.
• [39]Mahmood K, Eldeirawi K, Wahidi MM: Association of gender with outcomes in critically ill patients. Crit Care 2012, 16:R92. BioMed Central Full Text
• [40]Nachtigall I, Tafelski S, Rothbart A, Kaufner L, Schmidt M, Tamarkin A, Kartachov M, Zebedies D, Trefzer T, Wernecke KD, Spies C: Gender-related outcome difference is related to course of sepsis on mixed ICUs: a prospective, observational clinical study. Crit Care 2011, 15:R151. BioMed Central Full Text
• [41]Adielsson A, Hollenberg J, Karlsson T, Lindqvist J, Lundin S, Silfverstolpe J, Svensson L, Herlitz J: Increase in survival and bystander CPR in out-of-hospital shockable arrhythmia: bystander CPR and female gender are predictors of improved outcome. Experiences from Sweden in an 18-year perspective. Heart 2011, 97:1391-1396.
• [42]Bray JE, Stub D, Bernard S, Smith K: Exploring gender differences and the "oestrogen effect" in an Australian out-of-hospital cardiac arrest population. Resuscitation 2013, 84:957-963.
• [43]Wnent J, Seewald S, Heringlake M, Lemke H, Brauer K, Lefering R, Fischer M, Jantzen T, Bein B, Messelken M, Gräsner JT: Choice of hospital after out-of-hospital cardiac arrest - a decision with far-reaching consequences: a study in a large German city. Crit Care 2012, 16:R164. BioMed Central Full Text
• [44]Mancini ME, Soar J, Bhanji F, Billi JE, Dennett J, Finn J, Ma MH, Perkins GD, Rodgers DL, Hazinski MF, Jacobs I, Morley PT: Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010, (Suppl 2):S539-581.
• [45]Sasson C, Rogers MA, Dahl J, Kellermann AL: Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010, 3:63-81.
• [46]Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, Valsson F, Wanscher M, Friberg H, Hypothermia N: Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2009, 53:926-934.
• [47]Oddo M, Ribordy V, Feihl F, Rossetti AO, Schaller MD, Chiolero R, Liaudet L: Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular fibrillation cardiac arrest treated with hypothermia: a prospective study. Crit Care Med 2008, 36:2296-2301.
• [48]Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K: Strong and weak aspects of an established post-resuscitation treatment protocol-A five-year observational study. Resuscitation 2011, 82:1186-1193.
• [49]Rea TD, Dumas F: Resuscitation science: a role for observation? Resuscitation 2012, 83:281-282.
• [50]Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T: The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 2013, 84:337-342.
• [51]Arrich J, European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study G: Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med 2007, 35:1041-1047.